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Inferring semantic organization from

refractory access dysphasia: Further
replication in the domains of geography and
proper nouns but not concrete and abstract
concepts
a
A. Cris Hamilton & Randi C. Martin
a
Psychology Department, Rice University, Houston, TX, USA

Version of record first published: 30 Nov 2011.

To cite this article: A. Cris Hamilton & Randi C. Martin (2010): Inferring semantic organization from
refractory access dysphasia: Further replication in the domains of geography and proper nouns but not
concrete and abstract concepts, Cognitive Neuropsychology, 27:8, 614-635

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 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8), 614– 635

Inferring semantic organization from refractory access

dysphasia: Further replication in the domains of
geography and proper nouns but not concrete and
abstract concepts

A. Cris Hamilton and Randi C. Martin

Psychology Department, Rice University, Houston, TX, USA

Patients with “refractory access dysphasia” have been a source of unique insight into the organization
Downloaded by [201.141.53.213] at 06:48 11 October 2012

of previously unexplored domains of semantic knowledge (i.e., proper nouns, geography, concrete and
abstract concepts). However, much of the relevant data have been based on the performance of a small
number of patients. Here, we present 2 patients who both display a “refractory access” pattern of per-
formance on spoken-word –written-word matching tasks and test their performance in the domains of
famous people, geography, and abstract and concrete words. While these patients show performance
similar to that for the previously reported patients in the domains of famous people and geography,
they show a very different pattern of performance with abstract and concrete nouns. We discuss
possible reasons why patients may differ in performance and evidence for and against the “differential
frameworks” hypothesis for the organization of concrete and abstract concepts.

Keywords: Semantic organization; Refractory access; Abstract concepts.

Patients identified as having “refractory access
dysphasia” are characterized by a unique pattern
of performance when confronted with matching-
to-sample tasks tapping language comprehension.
First, their accuracy decreases as a function of rep-
etition. Second, their performance also declines
with faster presentation rates. For example, they
are worse with a 1-s response – stimulus interval
(RSI) than with a 10-s or 30-s RSI. Finally,
these patients are remarkably sensitive to semantic
relatedness—their performance is much better
when stimuli are grouped with semantically
disparate words than when stimuli are grouped
in arrays of semantically related words. It is this
sensitivity to semantic relatedness that has been
exploited to make inferences about the organiz-
ation of semantic knowledge. It is assumed that
items with greater semantic overlap (e.g.,
leopard, lion, cheetah, puma) would generate
greater semantic interference, while items with
fewer overlapping semantic representations
would yield comparatively smaller interference
effects. These effects have been observed in both
spoken-word – written-word matching (Crutch &

Correspondence should be addressed to A. Cris Hamilton, Rice University, 474 Sewall Hall, Houston, TX 77005, USA (E-mail:
a.cris.hamilton@rice.edu)

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Warrington, 2005) and spoken-word – picture
matching (Forde & Humphreys, 1995, 1997;
Warrington & Cipolotti, 1996).
It has been argued that patients with refractory
access dysphasia differ in several fundamental ways
when compared to patients with purely semantic
deficits (Jefferies, Baker, Doran, & Lambon,
2007). Patients with refractory patterns are
thought to have relatively spared semantic rep-
resentations, but mechanisms used to access
these representations are impaired. This is revealed
by the patients’ inconsistent performance with
repeated presentation of stimuli. Patients may cor-
rectly match spoken to written words on initial
presentation, but then incorrectly match the
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same words when presented again only seconds
later. By comparison, patients with purely seman-
tic deficits are reported to show much greater con-
sistency—they tend to miss the same items over
multiple trials and multiple testing sessions reflect-
ing the permanent loss of specific semantic rep-
resentations. Neuroanatomically, these patients
differ in that refractory access patients typically
have large lesions (often spanning frontal, parietal,
and superior temporal areas), while patients with
semantic deficits have typically sustained damage
to the anterior temporal areas following herpes
simplex viral encephalitis (HSVE) or during the
course of the semantic dementia variant of fronto-
temporal dementia (FTD; Hodges, Patterson,
Oxbury, & Funnell, 1992).
Patients with semantic deficits following
HSVE provided some of the first evidence that
categorical dissociations were possible following
brain damage (Warrington & Shallice, 1984).
However, recent data suggest that patients with
refractory access dysphasia may allow an even
finer grained analysis of semantic categories.
While patients with “category-specific” naming
disorders have typically demonstrated dis-
sociations between broad categories such as
animals and artefacts or living and nonliving
things, patients with refractory access dysphasia
have been used to make inferences about the
organization of semantic domains such as
famous people (Crutch & Warrington, 2004),
geography (Crutch & Warrington, 2003), and
REFRACTORY ACCESS DYSPHASIA
concrete and abstract words (Crutch &
Warrington, 2005).
For example, Crutch and Warrington (2004)
reported patient A.Z. who was described as
gravely aphasic and demonstrated the three cardi-
nal features of a refractory semantic access deficit.
A.Z. was administered a spoken-word – written-
word matching task that presented names of
cities that were organized by geographical proxi-
mity (i.e., Brighton, Southampton, Eastbourne,
Portsmouth) versus arrays that were geographi-
cally distant (i.e., Brighton, Norwich,
Manchester, Plymouth). Patient A.Z.’s spoken-
word – written-word matching was worse when
arrays were composed of geographically proximate
cities than when they were geographically distant,
presumably because the geographically related
stimuli were more closely organized in semantic
space and shared more semantic representation
leading to greater semantic interference. These
effects were recently replicated in two additional
patients by Crutch and Warrington (2010a).
A similar logic was used by Crutch and
Warrington (2004) who used a spoken-word –
written-word matching task to test patient A.Z.’s
performance on famous people. Here, they used
famous names in arrays organized by occupation
(i.e., politicians, broadcasters, etc.) compared to
arrays with famous names from different occu-
pations. Patient A.Z. was significantly less accu-
rate when names were organized by occupation
than when names belonged to different occu-
pations. Presumably, names organized more
closely in semantic space yield greater interference
effects, suggesting that occupation is one dimen-
sion by which famous people are organized in
the brain.
Another study with patient A.Z. (Crutch &
Warrington, 2005) examined the semantic organ-
ization of concrete and abstract words. As noted by
Crutch and Warrington, abstract concepts are
exceptionally difficult to study, given that they
are not straightforwardly depicted in pictures,
making them difficult to investigate using conven-
tional picture naming. When presented with a
spoken-word – written-word matching task,
Crutch and Warrington found that abstract
COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 615
 HAMILTON AND MARTIN
words did not show the typical semantic related-
ness effects. That is, abstract words placed in
synonymous arrays (i.e., divine, sacred, religious,
holy) did not elicit poorer performance than did
nonsynonymous arrays (i.e., divine, sparse,
furious, sudden). Abstract words are obviously dif-
ficult to assign to categories as they are not easily
grouped based on the dimensions that typically
form categories for concrete words. However,
this null effect motivated Crutch and
Warrington to explore other forms of related-
ness—specifically, semantic association. Abstract
words were placed in semantically associated
arrays, in which items did not share a semantic cat-
egory but instead were related based on “real-
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world or sentential contexts” (exercise, healthy,
fitness, jogging). When compared to performance
on unrelated arrays, A.Z.’s performance on
abstract words presented in semantically associated
arrays was revealed to be significantly worse.
Moreover, when concrete words were placed in
associatively related arrays (i.e., farm, cow,
tractor, barn), no interference was observed rela-
tive to unrelated arrays. Thus, Crutch and
Warrington had established a double dissociation
in patient A.Z.—her performance on abstract
words was influenced by semantic association,
while her performance on concrete words was
only influenced by semantic category. Crutch and
Warrington argued that these data suggested
that abstract and concrete concepts have funda-
mentally different principles of representation,
with abstract concepts being organized associa-
tively, while concrete words were organized by
semantic category. However, they also noted
that, “this associative/categorical dichotomy is
relative rather than absolute” (Crutch &
Warrington, 2005, p. 624).
That concrete words and abstract words are
processed differently is not controversial. For
example, normal subjects are faster to make
lexical decisions with concrete words (James,
1975) and have better short-term recall for con-
crete words (Walker & Hulme, 1999).
Traditionally, theorists have proposed that abstract
words differ primarily in the number of semantic
features associated with them (Paivio, 1986).
616 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
However, the “differential frameworks proposal”
offered by Crutch and Warrington (2005) is
unique in that it proposes different principles of
organization for concrete and abstract concepts.
One might reasonably assume that differing prin-
ciples of organization also suggests separate
systems dedicated to concrete or abstract concepts,
although Crutch and Warrington have contended
that qualitatively different principles of organiz-
ation do not necessitate separate systems (Crutch
& Warrington, 2010b). Interestingly, the pattern
of data reported by Crutch and Warrington
(2005) would seem to be at odds with numerous
priming studies that have reported priming for
associatively related concrete items. This is
especially interesting given that both refractory
access effects and associatively based priming
have been explained in terms of spreading acti-
vation (Collins & Loftus, 1975).
Although data from refractory access dysphasia
patients have provided useful insights into the
organization of previously unexplored semantic
domains, much of this work has been done with
a very small number of patients. A subsequent
attempt to replicate the previously reported dis-
sociations between concrete and abstract data
(Hamilton & Coslett, 2008) found a very different
pattern of performance, with refractory access
patient UM-103 showing significant interference
for concrete and abstract words regardless of
whether they were semantically related or associa-
tively related, suggesting the same principles of
organization for both concrete and abstract con-
cepts. More recently, Crutch and Warrington
(2010b) and Crutch and Jackson (2011) presented
additional patient data in support of the differen-
tial frameworks hypothesis.
Clearly, there are contradictory data in the lit-
erature, and it is thus valuable to examine
additional patients on the concrete/abstract dis-
tinction, including the manipulation of semanti-
cally related versus associated items. In the
current study, we report data from two patients
with aphasic profiles very similar to that of
patient A.Z. That is, they are globally aphasic
with moderately impaired comprehension and
very little language production. Moreover, both

Figure 1. Patient H.A. Lesion was traced in native space, then transformed to MNI (Montreal Neurological Institute) space and displayed on
MNI template using MRIcron (Rorden, Karnath, & Bonilha 2007). To view a colour version of this figure, please see the online issue of the
Journal.
patients appear to possess the three principle fea-
tures of refractory access dysphasia. We then
attempt to replicate the performance of patient
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A.Z. in the domains of famous people and geogra-
phy to establish that these cases are similar to pre-
viously presented cases. We then determine
whether these two patients show similar or differ-
ing patterns of interference when presented with
semantically related and associatively related con-
crete and abstract words.
Patient backgrounds
Patient H.A.
Patient H.A. was an 84-year old man who suffered
a cerebrovascular accident (CVA) in 2006. H.A.
had earned a bachelor’s degree in college and
worked in television broadcasting until his retire-
ment. His stroke resulted in a large left hemisphere
lesion that spanned frontal, parietal, and superior
aspects of the temporal lobe (see Figure 1). H.A.
was globally aphasic with very limited output,
such that naming tasks were not possible. For
example, he failed to produce any scorable
response to the picture description of the
Western Aphasia Battery (WAB; Shewan &
Kertesz, 1980) and no correct responses to the
object naming subtest. H.A. was only able to
repeat 4 of 14 words (29%) presented on the rep-
etition subtest of the WAB. His comprehension
of spoken words was also impaired. On the first
100 items of the Peabody Picture Vocabulary
Test (PPVT; Form L; Dunn & Dunn, 1981),
which requires matching a spoken word to the
correct item in an array of four pictures, H.A.
scored 68/100. However, he was much better
COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
REFRACTORY ACCESS DYSPHASIA
when provided a written word to match to the
same pictures, scoring 97/100. A similar pattern
was observed with stimuli from the
Psycholinguistic Assessments of Language
Processing in Aphasia (PALPA) version of the
spoken-word – picture matching task (PALPA
47), where he was 32/40 (80%) and 39/40 (98%)
on the written-word – picture matching (PALPA
48). H.A. scored 94% on the picture version of
the Pyramids and Palm Trees task (Howard &
Patterson, 1992) and 88% correct on the written
version, a task tapping semantic processing (per-
formance at 90% and above being considered
normal). On an auditory lexical decision task
(PALPA 5), he was 88% correct, which was
below the reported control mean of 95% correct
(Kay, Lesser, & Coltheart, 1992). He was 97%
correct on a visual lexical decision task (PALPA
27), which was the same as the reported mean of
controls. H.A. was very impaired at making two-
item visual homophone judgements (PALPA 15,
28/50 ¼ 56%), suggesting great difficulty in
accessing phonology from the printed word.
Patient D.Z.
Patient D.Z. was a 42-year-old woman who had
completed a master’s degree and was enrolled in
a doctoral program when she suffered a CVA in
2005. Her stroke resulted in a large left hemi-
sphere lesion that included frontal, parietal, and
temporal lobes (see Figure 2). D.Z. was also glob-
ally aphasic with extremely limited output. Much
like patient H.A. presented above, D.Z. could
not produce any output for the picture description
subtest of the Western Aphasia Battery (Shewan
617
 HAMILTON AND MARTIN
Figure 2. Patient D.Z. Lesion was traced in native space, then transformed to MNI (Montreal Neurological Institute) space and displayed on
MNI template using MRIcron (Rorden, Karnath, & Bonilha 2007).
& Kertesz, 1980) and repeated only 3 of 14 words
(23%) presented on the repetition subtest of the
WAB. She scored 84/100 with spoken words on
the first 100 items of the PPVT and scored simi-
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larly on the written version (81/100). Similarly,
she scored 29/40 (73%) on the PALPA version
of spoken-word – picture matching (PALPA 47)
and 30/40 (75%) correct on the written-word –
picture matching (PALPA 48). She was 83%
correct on the auditory lexical decision task
(PALPA 5, controls ¼ 95%) and 90% correct on
the visually presented lexical decision task
(PALPA 27, controls ¼ 97%). On the Pyramids
and Palm Trees task she showed impaired per-
formance, scoring 80.7% correct with the picture
version and 84.6% correct with the written
version. D.Z. was also very impaired at extracting
phonology from printed words, scoring 22/50
(44%) on visually presented homophone judge-
ments (PALPA 15).
EXPERIMENT 1
Both patients were tested on spoken-word –
written-word matching task that presented words
in semantically related (all words from same
semantic category) or unrelated arrays. This exper-
iment was intended to demonstrate that both
patients revealed the three essential features of a
“refractory access dysphasia”—that is, both
patients demonstrated worse performance with
repeated presentation of the same stimuli, sensi-
tivity to semantic relatedness, and better perform-
ance with increased RSI. With regard to RSI, we
tested each patient with a 10-s RSI (as reported
618 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
in Crutch & Warrington, 2005) and a 30-s RSI
(as reported in Forde & Humphreys, 1995, and
Warrington & McCarthy, 1983).
Method
Stimuli consisted of words sampled from four cat-
egories (fruit, vehicles, amphibians/reptiles, and
musical instruments; see Appendix) and were pre-
sented in both related and unrelated arrays. Arrays
of four words were presented on a white sheet of
8.5 × 11′′ paper. The experimenter (A.C.H.)
read a word aloud, and the patient was asked to
point to the word on the sheet of paper. Each
word was probed once per cycle. Four pseudoran-
domized cycles were presented. Thus, each word
was probed four times, creating 16 spoken-
word – written-word matching trials per array.
Stimuli were presented with a 1-s, 10-s, and 30-s
RSI on three separate days. The experimenter
(A.C.H.) allowed 1 s between the patients’
responses and the presentation of the next word
for the 1-s RSI and measured the 10-s and 30-s
RSIs with a hand-held timer. Administration of
the 1-s, 10-s, and 30-s RSI versions were separated
by several months.
Results
Data from Experiment 1 appear in Figure 3a.
Patient H.A. showed the typical effects of a refrac-
tory access dysphasia. He performed significantly
worse on the semantically related arrays (60.9%,
39/64) than on the unrelated arrays (89%, 57/
64), x2(1) ¼ 13.5, p ¼ .0001, one-tailed. His per-
formance also declined with repetition, such that
 REFRACTORY ACCESS DYSPHASIA
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Figure 3. Experiment 1. Patient H.A.: (a) Accuracy on related and unrelated trials collapsed over repetition cycles. (b) Errors for related and
unrelated trials at each repetition cycle. Patient D.Z.: (c) Accuracy on related and unrelated trials collapsed over repetition cycles. (d) Errors for
related and unrelated trials at each repetition cycle.

when results were collapsed over related and unre-
lated arrays, he was better at Cycle 1 (28/32 ¼
87.5%) than at Cycle 4 (19/32 ¼ 59.4%), x2(1)
¼ 6.488, p ¼ .005, one-tailed. Finally, H.A.’s
overall accuracy collapsed over related and unre-
lated trials was worse with a short 1-s RSI (96/
128 ¼ 75%) than with a long 30-s RSI (112/128
¼ 87.5%), x2(1) ¼ 6.564, p ¼ .005, one-tailed.
However, he showed no difference between the
1-s and 10-s RSI (94/128 ¼ 73%), x2(1) ¼
0.082, p ¼ .3875, one-tailed.
Patient D.Z. showed a similar pattern. She was
worse with semantically related arrays (43/64 ¼
67.2%) than with unrelated arrays (60/64 ¼

COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 619

 HAMILTON AND MARTIN

93.7%), x2(1) ¼ 14.366, p ¼ .0001, one-tailed. Results

Her accuracy also decreased with repetition. She
Both patients’ data appear in Figure 4. H.A. was
was 93.7% correct on Cycle 1 (30/32) and 75%
significantly worse on arrays composed of geo-
on Cycle 4 (24/32), x2(1) ¼ 4.267, p ¼ .0194,
graphically proximate cities (45/64 ¼ 70.3%)
one-tailed. D.Z.’s overall accuracy collapsed over
than on arrays consisting of geographically
related and unrelated trials was significantly
distant cities (58/64 ¼ 90.6%), x2(1) ¼ 8.401, p
worse with a short 1-s RSI (103/128 ¼ 80.4%)
¼ .0019, one-tailed. D.Z. showed the same
than with a long 30-s RSI (118/128 ¼ 92%),
pattern, being significantly worse on arrays with
x2(1) ¼ 7.447, p ¼ .0032, one-tailed. D.Z. failed
cities organized by geographical proximity (34/
to show any difference between the 1-s and 10-s
64 ¼ 53%) than on arrays of city names that
RSI (105/128 ¼ 82%), x2(1) ¼ 0.103, p ¼
were geographically more distant (50/64 ¼
.3744, one-tailed.
78.1%), x2(1) ¼ 8.87, p ¼ .0015, one-tailed.
Thus, both patients showed all three features of
Both patients H.A. and D.Z. showed similar
refractory access dysphasia—they were sensitive to
patterns to those for patient A.Z. reported by
semantic relatedness, showed an increase in errors
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Crutch and Warrington (2003)—greater interfer-

with repetition, and had better overall accuracy
with a 30-s RSI.
EXPERIMENT 2: GEOGRAPHY
Crutch and Warrington (2005, 2010a) previously
proposed that place knowledge may be uniquely
organized by a spatial code. Support for this
hypothesis came from experiments demonstrating
that city names presented in arrays composed of
geographically proximate cities resulted in greater
interference effects than did arrays composed of
geographically distant cities. Thus, we tested
patients H.A. and D.Z. with similar stimuli to
assess their correspondence with the previously
reported patients.
Method
Patients H.A. and D.Z. were tested on city names
using a spoken-word– written-word matching task
using familiar city names sampled from different
geographical regions. All cities were taken from
the continental United States, with four cities
being sampled from the north-east (Boston,
Philadelphia, Baltimore, New York), Midwest
(Chicago, Minneapolis, Detroit, Milwaukee),
Texas (San Antonio, Dallas, Houston, Austin),
and California (Oakland, Los Angeles, San
Diego, San Francisco).
ence effects were observed when performing
spoken-word – written-word matching with
arrays of cities that were geographically proximate
than with cities that were geographically distant.
EXPERIMENT 3: FAMOUS PEOPLE
A number of studies have suggested dissociations
between processing of proper nouns and
common nouns (see Semenza, 2009, for a recent
review). For example, Cipolotti, McNeil, and
Warrington (1993) reported a patient who
showed better performance with famous people’s
names than with common objects. Moreover,
some evidence suggests that famous proper
names might be a relatively preserved category of
knowledge in access dysphasia (Cipolotti &
Warrington, 1995). Finally, dissociations within
the category of proper nouns have been reported.
For example, Forde and Humphreys (1995)
reported a patient who was better with famous
names than with common first names (e.g., Bill,
Don, Jack).
Evidence that occupation may play an impor-
tant role in the semantic organization of famous
people comes from earlier studies examining
“covert recognition” of faces in prosopagnosia
(De Haan, Young, & Newcombe, 1987). These
studies required subjects to determine whether a
written name belonged to a specific occupation
(e.g., politician), but presented the names with

620 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)

 REFRACTORY ACCESS DYSPHASIA
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Figure 4. Experiment 2. Geographically proximate and distant cities. Patient H.A.: (a) Accuracy on geographically proximate and distant
arrays collapsed over repetition cycles. (b) Errors for proximate and distant arrays at each repetition cycle. Patient D.Z.: (c) Accuracy on
proximate and distant arrays collapsed over repetition cycles. (d) Errors for proximate and distant arrays at each repetition cycle.

pictures of faces sampled from the same occu-
pation or different occupations. These prosopag-
nosic subjects showed interference such that they
took longer to make decisions when names were
presented with faces from different occupations
than when names were presented with faces in
the same occupation.
More recently, Crutch and Warrington (2004)
provided further evidence that occupation is one
important dimension in the semantic organization
of famous people by demonstrating that patient
A.Z. showed greater semantic interference effects
when written arrays of famous names were pre-
sented with famous names from the same

COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 621

 HAMILTON AND MARTIN
occupation (i.e., Tony Blair, William Hague,
Gordon Brown, John Major) than when arrays
were composed of names of famous people from
different occupations. Hamilton and Coslett
(2008) reported the same pattern with patient
UM-103. Experiment 3 seeks to replicate this
effect with patients H.A. and D.Z.
Method
In Experiment 3, Patients H.A. and D.Z. were
tested on a spoken-word –written-word matching
task that presented the names of famous people
from four different occupations. Given differences
in age between H.A. and D.Z., different sets of
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stimuli were constructed for each patient. H.A.
was presented with baseball players (Babe Ruth,
Micky Mantle, Sandy Koufax, Roger Maris),
actors (Will Rogers, Charlton Heston, Burt
Lancaster, and John Wayne), news broadcasters
(Walter Cronkite, Tom Brokaw, Dan Rather,
and Ted Koppel), and U.S. presidents (Dwight
Eisenhower, Lyndon Johnson, Harry Truman,
John Kennedy).1 D.Z. was presented with
National Basketball Association (NBA) basketball
players (Kobe Bryant, Allen Iverson, Michael
Jordan, Shaquille O’Neal), contemporary actors
(Tom Cruise, Brad Pitt, Russell Crowe, Bruce
Willis), U.S. presidents (George Bush, Bill
Clinton, Ronald Reagan, John Kennedy), and
news broadcasters (Walter Cronkite, Tom
Brokaw, Dan Rather, and Ted Koppel). To
verify that the patients knew the occupations of
these famous names, we presented the mixed
arrays of famous people in a spoken-word –
written-word matching task, presenting the occu-
pation and having the patient point to the famous
person that belonged to that occupation. Both
patients performed at ceiling (16/16 correct). In
the spoken-word – written-word matching task,
the experimenter (A.C.H.) spoke aloud each
name, and the patient was instructed to point to
the target from among four names printed on a
page of 8.5 × 11′′ paper. As in previous
1
H.A. indicated he had once been interested in baseball and film but had lost interest in contemporary fare; thus he was presented
with mid-twentieth-century baseball players and actors.
622 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
experiments, each word was sampled four times.
The next name was read after a 1-s delay.
Results
Data from both patients appear in Figure 5. When
initially presented with these stimuli, Patient H.A.
was worse with names that were arranged in arrays
composed of names from the same occupation than
with items drawn from different occupations (same
occupation ¼ 59%, different occupations ¼ 64%),
although this difference did not reach statistical sig-
nificance. H.A. was tested two additional times sep-
arated by several months, and when combining over
all three administrations, he showed worse accuracy
on items drawn from the same occupation (64%)
than from an unrelated occupation (72%), which
was close to statistical significance, x2(1) ¼ 2.691,
p ¼ .0504, one-tailed.
By comparison, Patient D.Z. was dramatically
worse with names from the same occupation
(accuracy ¼ 62.5%) than with names drawn from
different occupations (accuracy ¼ 95.3%), x2(1)
¼ 20.7, p ¼ .0001. Thus, both H.A. and D.Z.
demonstrated the pattern previously observed in
Patient A.Z. (Crutch & Warrington, 2004) and
patient UM-103 (Hamilton & Coslett, 2008).
EXPERIMENT 4
Crutch and Warrington (2005) argued that patient
A.Z.’s performance on abstract and concrete words
suggested qualitatively different principles of
organization—abstract words organized by associ-
ative relations and concrete words organized by
semantic category. Subsequent patient data both
support (Crutch, Ridha, & Warrington, 2006)
and failed to replicate this pattern (Hamilton &
Coslett, 2008). Given the similarities between
patients H.A. and D.Z. to previously reported
cases (e.g., patient A.Z.; Crutch & Warrington,
 REFRACTORY ACCESS DYSPHASIA
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Figure 5. Experiment 3. Famous people from same occupation compared to different occupations. Patient H.A.: (a) Accuracy on related and
unrelated trials collapsed over repetition cycles. (b) Errors for related and unrelated trials at each repetition cycle. Patient D.Z.: (c) Accuracy on
related and unrelated trials collapsed over repetition cycles. (d) Errors for related and unrelated trials at each repetition cycle.

2003, 2005), Experiment 4 tested H.A. and D.Z.
on the concrete and abstract stimuli.
Method
Stimuli were adopted from the appendices of Crutch
and Warrington (2005). The experimenter (A.C.H.)
spoke aloud each word, and the patient was
instructed to choose the corresponding word from
among four names printed on a page of 8.5 × 11′′
paper. The next item was presented after a 1-s delay.
Results
Figures 6 and 7 present data from both patients in
Experiment 4. In contrast to data reported

COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 623

 HAMILTON AND MARTIN
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Figure 6. Experiment 4. Patient H.A.: Concrete and abstract words presented in semantically and associatively related arrays compared to
unrelated arrays. Column A: Accuracy for related and unrelated trials collapsed over repetition cycle. Column B: Errors for related and
unrelated trials at each repetition cycle.

624 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)

 REFRACTORY ACCESS DYSPHASIA
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Figure 7. Experiment 4. Patient D.Z.: Concrete and abstract words presented in semantically and associatively related arrays compared to
unrelated arrays. Column A: Accuracy for related and unrelated trials collapsed over repetition cycle. Column B: Errors for related and
unrelated trials at each repetition cycle.

COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 625

 HAMILTON AND MARTIN
previously by Crutch and Warrington (2005) and
Crutch et al. (2006), patients H.A. and D.Z.
showed a very different pattern of performance.
Both patients showed statistically significant inter-
ference effects for concrete and abstract words
when they were either associatively related or
semantically related. For the concrete words,
H.A. was much worse with semantically related
arrays (61% correct) than with unrelated arrays
(90% correct), x2(1) ¼ 28.823, p ¼ .0001, two-
tailed2. For the associatively related concrete
arrays, H.A. again showed interference, with
worse performance on the related (59%) than on
the unrelated condition (77%), x2(1) ¼ 9.554, p
¼ .002, two-tailed. With the abstract words,
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H.A. showed the same pattern, with both seman-
tically related arrays (semantically related ¼ 52%;
semantically unrelated ¼ 71%), x2(1) ¼ 9.953, p
¼ .0016, two-tailed, and associatively related
arrays (associatively related ¼ 57%, associatively
unrelated ¼ 75%), x2(1) ¼ 9.211, p ¼ .002, two-
tailed.
Patient D.Z. showed the same pattern with
statistically significant interference effects for
semantically related concrete words (related ¼
75%, unrelated ¼ 99%), x2(1) ¼ 32.431, p ¼
.0001, two-tailed, and associatively related con-
crete words (related ¼ 72%, unrelated ¼ 88%),
x2(1) ¼ 8.308, p ¼ .002, two-tailed. She showed
the same pattern for abstract words, whether
they were semantically related abstract words
(related ¼ 58%, unrelated ¼ 80%), x2(1) ¼
16.253, p ¼ .0001, two-tailed, or associatively
related abstract words (related ¼ 67%, unrelated
¼ 95%), x2(1) ¼ 24.712, p ¼ .0001, two-tailed.
We also tested the possibility that, although
these patients showed significant differences for
all conditions, the pattern of performance might
reveal greater impairment on semantically related
than on associatively related arrays for concrete
words and greater impairment on associatively
related than on semantically related arrays for
abstract words. This would be consistent with
2
Given that Crutch and Warrington (2010b) have reported facilitation on reading tasks using abstract and concrete stimuli in
associatively or semantically related arrays, two-tailed tests were used in Experiment 4.
626 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
the idea that both concrete and abstract words
are connected by both semantically mediated and
associatively mediated relationships, but that con-
crete words depend more heavily on semantic
relationships and abstract words more heavily on
associative relationships. Neither patient demon-
strated any significant difference between concrete
words in semantically related compared to associa-
tively related arrays—H.A., x2(1) ¼ 0.016, p ¼
.449, one-tailed; D.Z., x2(1) ¼ 0.021, p ¼ .443,
one-tailed—or abstract words in associatively
related compared to semantically related arrays—
H.A., x2(1) ¼ 0.484, p ¼ .243, one-tailed; D.Z.,
x2(1) ¼ 0.831, p ¼ .181, one-tailed.
EXPERIMENT 5: ABSTRACTNESS 3
FREQUENCY
One possible explanation for the very different
patterns of performance demonstrated by H.A.
and D.Z. in Experiment 4 could be their overall
ability to process concrete and abstract words rela-
tive to A.Z. To explore this possibility, we tested
both patient H.A. and patient D.Z. on a large
number of stimuli that were manipulated by con-
creteness and frequency (Experiment 1 in Crutch
& Warrington, 2005). While previous reports of
refractory access dysphasia have often reported an
absence of frequency effects in these patients,
Crutch and Warrington (2005) demonstrated
that patient A.Z. showed an unusual reverse fre-
quency effect whereby she was actually better
with spoken-word – written-word matching with
lower frequency words than with matching with
high-frequency words. Thus, examining frequency
effects in patients H.A. and D.Z. might be of
interest. Moreover, it has been noted (Crutch &
Warrington, 2010b) that the previous patient
reported to not replicate A.Z.’s double dissociation
with abstract and concrete stimuli did not show a
typical concreteness effect (i.e., improved perform-
ance with increasing concreteness, see Hamilton &
 REFRACTORY ACCESS DYSPHASIA

Coslett, 2008, Experiment 2). Unfortunately, it is Table 1. Patient performance with nouns varying in abstractness
difficult to fully assess concreteness effects in
Frequency
patient UM-103 given the data presented in
Hamilton and Coslett (2008). The words pre- Patient Abstractness LF MF HF Average
sented, which were borrowed from Crutch and
Warrington (2005), were all abstract, varying H.A. VLA 66 63 53 60
LA 59 78 66 68
only in the degree of abstractness. That is, the MA 78 74 78 77
stimuli were not composed of words along the 68 72 66 68
entire continuum of abstract to concrete.
D.Z. VLA 63 72 69 68
Nevertheless, it is important to determine LA 75 88 78 80
whether the patients presented here have a MA 69 94 91 84
similar absence of frequency effects3 (as reported Average 69 84 79 77
with many cases of refractory access dysphasia) or
Note: Crutch and Warrington (2005). VLA ¼ very low
even reversed frequency effects (as in Crutch & abstractness; LA ¼ low abstractness; MA ¼ medium
Warrington’s patient A.Z.) and whether their per-
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abstractness. LF ¼ low frequency; MF ¼ medium frequency;

formance is influenced by degree of abstractness. HF ¼ high frequency.

Method
We tested H.A. and D.Z. on the same materials as
those used to establish A.Z.’s reverse frequency
effect (Crutch & Warrington, 2005) to determine
whether H.A. and D.Z. demonstrated an absence
of frequency or concreteness effects in simple
spoken-word – written-word matching tasks. In
this experiment, each word was sampled once in
each array, with no repetition.
Results
As can be seen in Table 1, patient H.A. showed
better performance as words became less abstract,
although the effect was only marginal (very low
abstractness ¼ 60% correct, low abstractness ¼
68%, medium abstractness ¼ 77%), x2(2) ¼
5.398, p ¼ .067, two-tailed. Patient D.Z.’s per-
formance also improved as words became less
abstract (very low abstractness ¼ 68% correct,
low abstractness ¼ 80%, medium abstractness ¼
84%), x2(2) ¼ 8.265, p ¼ .016, two-tailed.
When examining frequency effects with these
stimuli, H.A. showed no significant frequency
effect (low frequency ¼ 67.7%, medium fre-
quency ¼ 72%, high frequency ¼ 66%), x2(2) ¼
0.9, p ¼ .637, two-tailed. In contrast, D.Z. did
show a frequency effect (low frequency ¼ 68.8%,
medium frequency ¼ 84%, high frequency ¼
79.2%), x2(2) ¼ 6.954, p ¼ .03, two-tailed.
However, it is of note that the frequency effect
for D.Z. was atypical, in that she performed non-
significantly better on the medium-frequency than
on the high-frequency words, x2(1) ¼ 0.874, p ¼
.35, two-tailed, and she showed no significant
difference between low-frequency and high-fre-
quency words, x2(1) ¼ 2.704, p ¼ .10, two-
tailed. The only significant difference was
between the low-frequency and the medium-fre-
quency items, x2(1) ¼ 6.531, p ¼ .01, two-tailed.
In summary, H.A. is very similar to other
patients with refractory semantic dysphasia reported
in the literature, in that he shows an absence of fre-
quency effects in spoken-word–written-word

3
Many have included the absence of frequency effects among the core features of refractory access dysphasia. However, the pre-
dicted status of frequency effects in refractory access patients is somewhat unclear. Some have argued for weakened or attenuated
frequency effects (in comparison to exaggerated effects of frequency seen in patients with storage deficits) or even an absence of
effects (i.e., no statistically significant effects). However, there have been refractory access patients reported with significant frequency
effects (Warrington & McCarthy, 1983), with an absence of frequency effects (Hamilton & Coslett, 2008) and even reversed fre-
quency effects (Crutch & Warrington, 2005).

COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 627

 HAMILTON AND MARTIN
matching tasks. Patient D.Z. did show a statistically
significant frequency effect, but only between low-
frequency and medium-frequency words, and not
between low-frequency and high-frequency or
between medium-frequency and high-frequency
words. This is in contrast to patient A.Z. (Crutch
& Warrington, 2005) who showed a reversed fre-
quency effect. In addition, H.A. and D.Z. both
showed better performance as words became less
abstract using these stimuli, although this trend
failed to reach statistical significance in H.A.’s case.
GENERAL DISCUSSION
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Patients with features of refractory access dyspha-
sia have been important sources of data in making
inferences about semantic organization. While
these studies have motivated several novel hypoth-
eses regarding semantic organization, the data
have come from very few patients. Given that
the constellation of performance termed “refrac-
tory access dysphasia” may vary across patients,
and some have even questioned its validity (Rapp
& Caramazza, 1993), replication is especially
important in this area. Thus, we attempted to
replicate a number of findings reported in the lit-
erature to determine which patterns are replicable
in two patients showing the three primary features
of refractory access dysphasia.
Patient D.Z. and H.A. were very similar to
other patients identified as having refractory
access dysphasia (patient A.Z. from Crutch &
Warrington, 2003, 2005; patient J.M. from
Forde & Humphreys, 1995, 1997, 2007) in that
they were both globally aphasic, with very
limited spoken output and similar overall patterns
of impairment in language processing.
Experiment 1 revealed both patients to have all
the hallmarks of refractory semantic access impair-
ment. On spoken-word– written-word matching
tasks their performance was highly variable, but
declined with repetition of the same stimuli.
Performance improved when response – stimulus
intervals increased from 1 s to 30 s. Most impor-
tantly, both patients were extremely sensitive to
semantic relatedness of items, performing
628 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
significantly worse when items were selected
from arrays composed of semantically related
items than when they were from semantically
unrelated arrays.
In Experiment 2, both patients showed a
similar pattern of performance when presented
with proper nouns related to cities, replicating
three previous case studies by Crutch and
Warrington (2003, 2010a) and providing further
support for the hypothesis that semantic represen-
tations related to geography might have a substan-
tial spatial component as proposed by Crutch and
Warrington (2003, 2010a). Of course, it may be
argued that geographically proximate cities prob-
ably share other features in addition to spatially
defined geography. For example, one might
argue that cities sharing geographical proximity
(e.g., cities in the north-east US) also share topo-
graphy, fauna, dialect, history, and cuisine that
might be represented in a nonspatial code.
Cleverly designed future work with patients and
healthy subjects should be able to arbitrate
between these two hypotheses.
In Experiment 3, D.Z. and H.A. were tested
with additional proper nouns, this time with the
category of famous people. Again, these patients
were remarkably similar to patients A.Z. (Crutch
& Warrington, 2004) and UM-103 (Hamilton
& Coslett, 2008), in that they showed greater
interference when presented with arrays of
famous people drawn from the same occupation
than when presented with arrays of famous
people from different occupations. These data
provide further support that occupation may be
one of the primary features along which knowl-
edge of famous people are organized (Crutch &
Warrington, 2004).
However, when examining performance on
abstract and concrete words in Experiment 4,
these patients diverged markedly from previously
reported patients A.Z. (Crutch & Warrington,
2005) and I.R.Q. (Crutch et al., 2006). Unlike
patient A.Z., who yielded no difference between
associatively related concrete words and synony-
mously related abstract words, both patient H.A.
and patient D.Z. showed statistically significant
differences when concrete and abstract words

were placed in related arrays, regardless of whether
the arrays were semantically or associatively
related. Thus, patients D.Z. and H.A. demon-
strated the same pattern of performance on con-
crete and abstract words as did patient UM-103
previously reported by Hamilton and Coslett
(2008).
Finally, Experiment 5 looked at patient D.Z.
and H.A.’s performance on stimuli manipulated
for abstractness and frequency. As has been the
case with many previously reported access patients,
H.A. showed no significant effects of word fre-
quency. D.Z., on the other hand, did show a stat-
istically significant, although atypical, frequency
effect. Specifically, she was significantly better
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with medium-frequency than with low-frequency
words, but showed no significant effect between
low-frequency and high-frequency words or
between medium-frequency and high-frequency
words.
In the next section, we evaluate the evidence for
the “differential frameworks model” and suggest
hypotheses as to why patients H.A., D.Z., and
UM-103 (Hamilton & Coslett, 2008) might
differ from other patients reported by Crutch
and colleagues.
Reassessing evidence for the differential
frameworks model
Crutch and Warrington (2005) first introduced
the “differential frameworks model” based on
data from patient A.Z. A subsequent study of a
bilingual patient, I.R.Q., was offered as further
support (Crutch et al., 2006). As pointed out in
Hamilton & Coslett (2008), the patient data sup-
porting the differential frameworks model might
be considered somewhat equivocal. First, the orig-
inal data rested crucially on a null effect—that is,
no differences between related and unrelated
abstract words presented in synonymous arrays
and no difference between related and unrelated
concrete words presented in associatively related
arrays. It is of note that these null effects were pre-
sented in the context of a very limited number of
stimuli—eight sets of four words in each of the
related and unrelated conditions for concrete and
REFRACTORY ACCESS DYSPHASIA
abstract words. As detailed in Hamilton and
Coslett (2008), the subsequent Crutch et al.
(2006) study of patient I.R.Q. was equivocal
given that close inspection of the data revealed
variability in performance on unrelated stimuli
that generated the critical null effect for synon-
ymous abstract words (see Figure 4 of Crutch
et al., 2006). More specifically, the patient was
equally poor on abstract words presented in
semantically related arrays as on abstract words
presented in associatively related arrays.
However, the patient’s performance on the unre-
lated arrays also differed in these two conditions,
giving the impression of a null effect for abstract
words in semantically related arrays. It is impor-
tant to emphasize that there is no reason to antici-
pate any performance difference, other than
random variation, in the unrelated arrays in these
two conditions. The effect should be driven by
better performance on abstract words organized
in semantically related arrays than on abstract
words in associatively related arrays, not in the
decreased performance for unrelated arrays.
More recently, Crutch and Warrington (2010b)
have offered additional data from patient F.B.I. in
support of a revised version of the differential fra-
meworks hypothesis, which they term the “differ-
ential dependence hypothesis”. F.B.I. is very
different from the patients presented in this
paper (and patient A.Z.) in that he had sufficient
production abilities to allow testing of his
reading. Crutch and Warrington (2010b) conclude
that F.B.I. demonstrated the same pattern of
results as patient A.Z. in spoken-word –written-
word matching tasks and the analogous pattern
of facilitation in reading tasks. Patient F.B.I. was
better at reading concrete words when they were
presented with semantically related words and
better at reading abstract words when they were
presented with associatively related words. In con-
trast, he showed no facilitation for associated con-
crete words or synonymous abstract words.
However, it is important to note that in one of
the spoken-word – written-word matching exper-
iments, patient F.B.I. showed only half of the
crucial dissociation. Specifically, for concrete
words, F.B.I. actually showed statistically
COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 629
 HAMILTON AND MARTIN
significant effects of semantic association
(although subsequent testing with additional
stimuli were offered to establish the null effect).
Thus, three patients have been reported to demon-
strate the pattern supporting a differential frame-
works model (to varying degrees), while patients
D.Z. and H.A. represent the second and third
patients that fail to demonstrate the dissociation.
Other data from the reading errors of patients
with deep dyslexia have also been reported to
support the differential frameworks hypothesis.
Crutch (2006) performed a post hoc analysis of
semantic reading errors of four deep dyslexic patients
originally reported by Coltheart, Patterson, and
Marshall (1980). This analysis revealed a greater
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number of associatively related errors than semanti-
cally related errors when reading abstract words and
more semantically related errors for concrete words.
However, it is of note that the Crutch (2006) analysis
judged over 35% of the reading errors to abstract
words to be semantically similar rather than associ-
ated. Of further note, poorer performance on
abstract words than on concrete words is a near-uni-
versal feature of deep dyslexia. Indeed, the four
patients reported by Crutch (2006) made nearly
three times as many errors on abstract words than
on concrete words. Given deep dyslexics’ particular
difficulty with abstract words, it seems likely that a
large percentage of errors for these patients might
merely be concrete responses to abstract targets,
which are necessarily associated. Inspection of the
Coltheart et al. (1980) data reveals many such
errors (e.g., phase  moon; amount  money;
condemn  prison).Whether such errors reflect
the organization of abstract semantics or simply a
bias toward concrete words in deep dyslexia is
unclear.
Finally, it is of note that behavioural data from
healthy subjects has recently been marshalled as
further evidence for the differential frameworks
model (Crutch, Connell, & Warrington, 2009;
Crutch & Jackson, 2011;Dunabeitia, Aviles,
Afonson, Scheepers, & Carreiras, 2009).
Dunabeitia et al. (2009) measured eye movements
in a visual-world paradigm. They auditorily pre-
sented abstract or concrete Spanish words that
were associated with a target in an array of four
630 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
pictures. They found that subjects were more
likely to fixate pictures that were associated to
auditorily presented abstract words than those
that were associated with auditorily presented con-
crete words. Of note, the same pattern was
observed when concrete words were presented,
but to a lesser extent. This suggests that associative
relationships were relevant for both concrete and
abstract words, but to a greater extent for abstract
words. This pattern of data can be interpreted as
supporting a version of the differential dependence
hypothesis. However, Dunabeitia et al. tested only
associative relatedness and did not evaluate seman-
tic similarity or synonymy in the organization of
concrete and abstract words using their method-
ology. Also of note, this experiment tested associ-
ative relationships between an abstract word and a
concrete concept (the picture), not associative
relationships between two abstract concepts.
Crutch and Jackson (2011) recently examined
the role of semantic similarity and association
with concrete and abstract words using an odd-
one-out paradigm with normal subjects. Subjects
were presented four words in a single display and
selected which item did not fit with the other
items. Abstract, middle-concreteness, and con-
crete stimuli were selected and placed in related
arrays. These arrays were rated for both semantic
association and semantic similarity. Using a mul-
tiple regression approach, the authors found a stat-
istically significant interaction between semantic
similarity and concreteness such that reaction
times (RTs) were faster for concrete stimuli as
semantic similarity increased. For associative relat-
edness, RTs decreased as words became more
abstract, although the critical interaction was not
statistically significant (p ¼ .07). Crutch and
Jackson (2011) also adapted the stimuli for use
with a spoken-word – written-word matching
task administered to N.B.C., a patient with
semantic refractory access dysphasia. This patient’s
pattern of performance on the spoken-word –
written-word matching task was similar to the
pattern reported for normal subjects in the odd-
one-out tasks. However, inspection of patient
N.B.C.’s data reveals the same problem as that
outlined above for patient I.R.Q. (Crutch et al.,

2006). One of the critical null effects was driven by
worse performance in an unrelated condition—
whether abstract words were presented in low-
similarity or high-similarity arrays made no differ-
ence to the patient’s performance. The null effect
is the result of random variability in performance
on the unrelated condition (see Crutch &
Jackson, 2011, Figure 3).
In addition, Crutch and Jackson (2011) stated:
“The observation of patients showing association
and similarity effects for both abstract and concrete
words is not capable of refuting or negating this
evidence from healthy individuals.” However, we
would argue that this depends on the strength of
such evidence from healthy individuals. Failing
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to replicate the original pattern with patients (all
of which show remarkable overlap with the other
patients reported in the literature other than
their performance on concrete and abstract
stimuli) invites scrutiny of the behavioural
studies with normal subjects. Our examination of
these studies reveals questions concerning the
interpretation of some of those data.
Finally, returning to the data presented here, we
also found no evidence for a version of the differen-
tial dependence hypothesis that predicts only a rela-
tive difference between concrete and abstract words
and their reliance on associative or similarity-based
relationships. For example, if concrete words
depend more strongly on similarity (but also have
weaker associative connections), and abstract
words depend more strongly on association (but
also have weaker connections based on similarity),
one might anticipate significant differences
between concrete and abstract words in both asso-
ciatively related and semantically related arrays,
but larger effects for semantically related concrete
arrays than for associatively related concrete arrays
and stronger effects for associatively related abstract
arrays than for semantically related abstract arrays.
However, neither of the patients in this study
revealed any statistically significant differences
between any of the related conditions.
It is of interest that there exists a substantial lit-
erature reporting priming for associatively related
words, including concrete words (e.g., bread
primes butter; see Hutchison, 2003, for a review
REFRACTORY ACCESS DYSPHASIA
of associative and feature-based semantic
priming). This literature would seem to be
especially relevant to the original Crutch and
Warrington (2005) account, given that priming in
normal subjects has been explained in terms of
“spreading activation” models (Collins & Loftus,
1975), just as Crutch and Warrington (2005) used
spreading activation to account for refractory
effects. Moreover, studies have reported “mediated
priming”, such that lion primes stripes, presumably
by way of tiger, which would appear to be necess-
arily mediated by associative connections among
concrete words (Chwilla & Kolk, 2002).
Moreover, Shelton and Martin (1992) have
argued that much of automatic semantic priming
is actually associative priming. Similarly, the
review of the literature by Hutchison (2003) came
to the conclusion that automatic semantic priming
does not occur for category coordinates but does
occur for associates and for some semantic relations
like synonymy. Thus, there also exist data from
normal subjects suggesting that concrete words are
organized by both semantic similarity and associat-
ive relationships. Whether the relative influence of
semantic and associative relationships varies across
the entire continuum of abstract to concrete
remains to be demonstrated in a priming paradigm.
What might account for the differences
across patients?
Although the patients reported here did not show
the pattern expected by the differential frame-
works hypothesis, one might question whether
there is some way to accommodate the present
findings that would be in accord with that hypoth-
esis. Of course, finding a different pattern of per-
formance for some patients does not necessarily
undermine the theoretical conclusions drawn
from contrasting patterns shown by other patients.
For example, finding that some patients show a
pattern of phonological dyslexia does not under-
mine the conclusion of a role for sublexical
letter – sound conversion deduced from the
reading pattern shown by surface dyslexics.
However, both sets of data need to be accommo-
dated by the theoretical framework. Currently, it
COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 631
 HAMILTON AND MARTIN
is unclear how the differential frameworks could
account for the equivalent effects for semantically
and associatively related terms for abstract and
concrete words that were reported here. Below
we consider some possible ways in which the
current findings might be accommodated.
Conceding for a moment the assumptions of the
differential frameworks hypothesis, one reason
these patients might differ is variability between
patients within the core features of “refractory
semantic access dysphasia”. On one hand, given
that such patients have large lesions, encompassing
frontal, parietal, and temporal lobes, and are glob-
ally aphasic, the correspondence across patients
with regard to the three core features outlined
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above is rather remarkable. Moreover, many of
these patients show very similar patterns of per-
formance across multiple semantic domains (i.e.,
geography, famous people, etc.). However, it is
not surprising that these patients might differ on
dimensions such as degree of impairment on
abstract concepts or the presence (patient D.Z.),
absence (patient H.A.), or reversal of frequency
effects (patient A.Z.; Crutch & Warrington,
2005). It is possible that variability on these and
other dimensions might reflect qualitative differ-
ences in access disorders among patients.
More specifically, one possibility is that the
temporal dynamics of refractory states might
differ across patients, such that it may take
longer for some patients to emerge from a refrac-
tory state. For example, in the current experiments,
we used a 30-s RSI (as used in Forde &
Humphreys, 1995, and Warrington &
McCarthy, 1983) to demonstrate an effect of pres-
entation rate after finding that a 10-s RSI (as
employed by Crutch & Warrington, 2005) was
not sufficient to reveal differences. Thus, one
might speculate that the patients reported here
have a longer or more dense refractory state that
allows spreading activation to reach represen-
tations that are more distantly organized by associ-
ative or semantic relatedness for both concrete and
abstract concepts. If we are to assume that concrete
words are most closely organized by semantic
relatedness but also have more distant associative
connections, the more persistent refractory states
632 COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8)
in patients D.Z. and H.A. might obscure differ-
ences that were more apparent with A.Z.’s
weaker refractory effects. Similarly, this account
might explain the effects of associative and seman-
tic relatedness observed in D.Z. and H.A. with
abstract words. We presently have no data that
speak directly to this possibility.
However, given that patient A.Z. (Crutch &
Warrington, 2005), patient UM-103 (Hamilton &
Coslett, 2008), and patients D.Z. and H.A. have
all been tested with the same concrete and abstract
stimuli from Crutch and Warrington (2005;
Experiment 4 here), we can rule out the possibility
that differences in overall severity of impairment
are responsible for the disparate patterns. While
patient UM-103 (Hamilton & Coslett, 2008) was
more severely impaired on both concrete and
abstract words than was A.Z., patient H.A.’s
overall performance appears to be very similar to
that of A.Z., as does D.Z.’s (whose performance is
numerically better than that of A.Z.).
Finally, it is of note that patient A.Z. (Crutch
& Warrington, 2005), the patient providing the
best patient evidence for the differential frame-
works account, is unique in that she actually
showed a reverse frequency effect—she was sig-
nificantly more accurate with low-frequency
words. While weak or complete absence of fre-
quency effects is typical with cases of refractory
access dysphasia, A.Z. represents the only reported
case of reverse frequency effects. Thus, one might
posit that there exist other unique features of
A.Z.’s deficit that result in the original dissociation
between concrete and abstract words.
One other possible means of accounting for the
differences between the patients could be to
assume differences in the functional locus of the
deficit in terms of the level of word representation
that is impaired. In the priming literature, it has
long been suggested that associative and semantic
priming occur at different levels of representation.
While semantic priming is thought to occur at the
level of semantic representation, associative
priming has been argued to be based in co-occur-
rence at the lexical level (Moss, Hare, Day, &
Tyler, 1994; Shelton & Martin, 1992). However,
it has often been assumed that effects of semantic

relatedness observed in patients with refractory
semantic access dysphasia must occur at a semantic
level, although most of these studies (including the
present experiments) have not reported data from
multiple modalities (i.e., pictures and words) or
multiple tasks. Thus, that these effects occur at
some other level of representation (i.e., lexical)
has rarely been ruled out. The exception is
patient J.M. (Ferrand & Humphreys, 1996;
Forde & Humphreys, 1995, 1997, 2007). J.M.
was tested extensively on variations of spoken-
word matching tasks and showed interference
effects that spread from words to pictures (Forde
& Humphreys, 1997) and across languages (J.M.
was fluent in six languages), providing strong evi-
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dence of a semantic locus of the effects (Ferrand &
Humphreys, 1996). It is possible that refractory
access dysphasia patients differ in damage to separ-
able functional foci (i.e., lexical vs. semantic) and
that these deficits might interact with overall
damage to semantic representations for abstract
and concrete words, yielding different patterns of
performance on associatively and semantically
related concrete and abstract words. Whether or
not identifying the functional locus of
damage would provide evidence supporting the
differential frameworks hypothesis or a hypothesis
of a common framework with equivalent
weight for associative and semantic relations for
abstract and concrete words cannot be determined
at this point. It seems clear, however, that future
work in this area must attempt to more clearly
define the locus of these refractory effects, thus
facilitating comparison of patients across studies.
CONCLUSIONS
In summary, it would appear that the evidence for
the “differential frameworks” hypothesis is pre-
sently equivocal and should be evaluated more
closely. The patients reported here provide no evi-
dence that abstract words are represented primarily
by associative relationships, whilst concrete words
are represented primarily by taxonomic similarity
(Crutch et al., 2009). Instead, the present data
(as well as a substantial priming literature
REFRACTORY ACCESS DYSPHASIA
demonstrating associative priming for concrete
words) suggest that both concrete and abstract
words are linked both via associative connections
and by available semantic features. Although
patients showing a different pattern of deficits
from that in previously reported cases do not
necessarily undermine a particular theoretical
approach, it is nonetheless necessary for this theor-
etical approach to find some means of accommo-
dating the disparate findings. At present, it is
unclear to us how the similar effects of semantic
and associative relations for both concrete and
abstract terms could be accommodated by the
differential frameworks hypothesis, as currently
specified. Above we have made some suggestions
regarding how the differing results across different
patient might be accommodated. Whether or not
these possibilities are correct and whether they
would be consistent with the differential frame-
works hypothesis can only be determined
through further investigation.
Manuscript received 2 December 2010
Revised manuscript received 5 July 2011
Revised manuscript accepted 18 July 2011
First published online 10 November 2011
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APPENDIX

Stimuli used in Experiment 1

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Columns were used to construct related arrays; rows were used

to construct unrelated arrays.

Stimuli used in Experiment 1

Reptiles/
Fruits Vehicles Amphibians Instruments
orange truck snake guitar
apple car turtle drum
lemon boat frog trumpet
strawberry train lizard flute

COGNITIVE NEUROPSYCHOLOGY, 2010, 27 (8) 635